The nurse notes a nonreassuring pattern of the fetal heart rate. The mother is already lying on her left side. What nursing action is indicated?
Change her position to the right side.
Place a wedge under the left hip.
Lower the head of the bed.
Place the mother in a Trendelenburg position.
The Correct Answer is B
Choice A: Change her position to the right side
Changing the mother’s position to the right side can sometimes help improve fetal oxygenation by relieving pressure on the vena cava. However, since the mother is already lying on her left side, which is typically the preferred position to optimize blood flow, changing to the right side may not be as effective .
Choice B: Place a wedge under the left hip
Placing a wedge under the left hip is a common intervention to improve uteroplacental blood flow. This position helps to tilt the uterus off the vena cava, enhancing venous return and improving cardiac output, which can positively affect fetal oxygenation. This is why it is the correct answer.
Choice C: Lower the head of the bed
Lowering the head of the bed can help increase blood flow to the upper body and brain, but it does not specifically address the issue of improving uteroplacental blood flow. This action is less targeted for resolving nonreassuring fetal heart rate patterns.
Choice D: Place the mother in a Trendelenburg position
The Trendelenburg position, where the mother is laid flat on her back with her feet elevated higher than her head, is generally used to treat hypotension or to improve venous return in cases of shock. However, it is not typically recommended for nonreassuring fetal heart rate patterns as it can increase pressure on the diaphragm and reduce respiratory efficiency.
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Correct Answer is C
Explanation
Choice A reason:
The cord is still pulsating. This is not the first thing a nurse must ensure when the head comes out because the cord normally pulsates until the placenta is delivered. The pulsation indicates that the cord is still functioning and transferring blood and oxygen between the baby and the placenta. However, this does not mean that the cord is free from any complications that could endanger the baby's life, such as a nuchal cord (a cord wrapped around the neck) or a prolapsed cord (a cord that slips out before the baby). • Choice B reason:
The cord is intact. This is not the first thing a nurse must ensure when the head comes out because the cord is usually intact until it is clamped and cut after the delivery of the baby. The cord can be ruptured by excessive traction or twisting, which can cause bleeding and shock in the baby. However, this is a rare occurrence and does not pose an immediate threat to the baby's life as long as the cord is still attached to the placenta. • Choice C reason:
No part of the cord is encircling the baby's neck. This is the correct answer because a nuchal cord can cause compression of the cord and reduce blood flow and oxygen to the baby, leading to fetal distress, hypoxia, and brain damage. A nuchal cord occurs in about 10 to 30 percent of deliveries and can be detected by feeling for a loop of cord around the neck as the head emerges. If a nuchal cord is present, it should be gently slipped over the head or clamped and cut before delivery of the shoulders. • Choice D reason:
The cord is still attached to the placenta. This is not the first thing a nurse must ensure when the head comes out because the cord is always attached to the placenta until it separates from the uterine wall and is expelled after the delivery of the baby. The placenta provides nourishment and oxygen to the baby through the cord. However, this does not mean that the cord is free from any complications that could endanger the baby's life, such as a nuchal cord or a prolapsed cord.
Correct Answer is D
Explanation
Choice A reason:
Measuring urinary output. This is not the priority nursing care associated with an oxytocin infusion, because urinary output is not directly affected by oxytocin. Urinary output may be affected by other factors, such as fluid intake, dehydration, or kidney function, but these are not related to oxytocin administration. • Choice B reason:
Evaluating cervical dilation. This is also not the priority nursing care associated with an oxytocin infusion, because cervical dilation is a result of uterine contractions, not oxytocin itself. Oxytocin is used to stimulate or augment uterine contractions, but it does not cause cervical dilation directly. Cervical dilation is important to monitor during labor, but it is not the main focus of oxytocin infusion. • Choice C reason:
Increasing infusion rate every 30 minutes. This is not the priority nursing care associated with an oxytocin infusion, because increasing the infusion rate every 30 minutes is not a standard protocol for oxytocin administration. The infusion rate should be adjusted according to the patient's response and the provider's orders, but not arbitrarily or routinely. Increasing the infusion rate too quickly or too often can cause hyperstimulation of the uterus, which can be dangerous for both the mother and the fetus.
• Choice D reason:
Monitoring uterine response. This is the correct answer and the priority nursing care associated with an oxytocin infusion, because oxytocin can cause excessive or prolonged uterine contractions, which can lead to fetal distress, uterine rupture, or placental abruption. Therefore, the nurse must monitor the frequency, duration, and intensity of uterine contractions, as well as the fetal heart rate and blood pressure, to ensure that oxytocin is having the desired effect and not causing any adverse outcomes.
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